Chemotherapy Induced Nausea and Vomiting

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One of the most feared side effects of chemotherapy is nausea. Nausea can affect quality of life in many ways. It can make eating and maintaining proper nutrition a challenge. It can make everyday activities, such as bathing, preparing meals, working, and spending time with family and friends more difficult. And it can also make a cancer patient feel anxious and depressed. It may even discourage the person from continuing with treatment.

Chemotherapy-induced nausea and vomiting (CINV) is a common side effect of chemotherapy treatment. Nausea is characterized by an unpleasant feeling in the back of the throat or a queasy feeling in the stomach. Not everyone will experience nausea and/or vomiting from chemotherapy.

Classification of Nausea and Vomiting
Acute CINV
  • Begins a few minutes or up to several hours after chemo ends
  • These side effects usually come and go quickly, and stop within 24 hours

Delayed CINV
  • Unlike acute CINV, delayed CINV means your symptoms might not begin until more than 24 hours after chemo finishes
  • The symptoms might also last several days. In fact, some people can experience delayed nausea for up to 7 days

Breakthrough CINV
  • Sometimes CINV occurs even when you’ve taken preventative medication
  • This type of CINV may require higher doses of medication or even a different type of antinausea medication

Treatment-resistant CINV (also known as refractory CINV)
  • This type of CINV occurs after taking antinausea medication that has worked before but is no longer controlling the CINV symptoms

Cause
When chemotherapy drugs enter the body, an area of the brain receives signals, either directly or indirectly, which can trigger nausea and/or vomiting. For example, nausea may result when chemotherapy drugs damage the cells that line the gastrointestinal tract. In addition, certain other triggers, such as sights, smells, taste, motion, anxiety, or pain can also stimulate nausea and/or vomiting.

Risk Factors
Not all cancer patients will experience nausea, vomiting (emesis), or both. The most common causes are emetogenic chemotherapy drugs and radiation therapy to the gastrointestinal (GI) tract, liver, or brain. Several patient characteristics have also been identified. These include:
  • Being female
  • Age : under 55 years old
  • History of chronic high intake of alcohol
  • History of previous CINV
  • Anticipation of CINV
  • Anxiety or nervousness before cancer treatment
  • Poor control of CINV in previous episodes
  • History of nausea and vomiting during pregnancy
  • History of motion sickness
  • Cancer of the brain, liver, colon, or stomach
  • Constipation
  • Certain pain meds
  • Fluid and or electrolyte imbalance
Classification of Emetogenic Agents
HIGHLY EMETOGENIC AGENTS
  • Cisplatin
  • Dacarbazine
  • Cyclophosphamide (>1500 mg/m2)
  • Carmustine (>250 mg/m2)
  • Mechlorethamine
  • Streptozocin
  • ABVD
  • MOPP/COPP/BEACOPP
  • CBV
  • VIP
  • PEB
  • AC

MODERATELY EMETOGENIC AGENTS
  • Carboplatin
  • Methotrexate
  • Doxorubicin/Adriamycin
  • Docetaxe
  • Paclitaxel
  • Etoposide
  • Ifosfamide
  • Cyclophosphamide (≤1500 mg/m2)
  • CHOP/CHOP-R
Treatments
Antiemetic agents are the most common intervention in the management of treatment-related nausea and vomiting (emesis). The basis for antiemetic therapy is the neurochemical control of vomiting. Although the exact mechanism is not well understood, peripheral neuroreceptors and the chemoreceptor trigger zone (CTZ) are known to contain receptors for serotonin, histamine (H1 and H2), dopamine, acetylcholine, opioids, and numerous other endogenous neurotransmitters. Many antiemetics act by competitively blocking receptors for these substances, thereby inhibiting stimulation of peripheral nerves at the CTZ and possibly at the vomiting center. Most drugs with proven antiemetic activity can be categorized into one of the following groups:
  • Phenothiazines
    • Prochlorperazine
    • Butyrophenones
      • Droperidol and haloperidol
      • **Dopamine 2 Antagonist
        • Metoclopramide
    • 5-HT3 Receptor Antagonists
      • Ondansetron
      • Granisetron
      • Dolasetron
      • Palonosetron
      • Substance P Antagonists (NK-1 Receptor Antagonists)
      • Corticosteroids
      • Cannabis
      • Benzodiazepines
        • Lorazepam
        • Olanzapine
        • Alternative treatments
          • Lifestyle changes
          • Hypnosis
          • Behavioral therapy
          • Relaxation and Guided Imagery
          • Accupuncture
Antiemetic Recommendations by Emetic Risk Categories
Emetic Risk Category
 ASCO Guidelines
 NCCN Guidelines
High (>90%) risk
 Three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy.
 Prechemotherapy, a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam.
For patients receiving cisplatin and all other agents of high emetic risk, the two-drug combination of dexamethasone and aprepitant recommended for prevention of delayed emesis.
 For prevention of delayed emesis, dexamethasone (8 mg) on days 2–4 plus aprepitant (80 mg) on days 2 and 3 recommended, with or without lorazepam on days 2–4.
Moderate (30%–90%) risk
 For patients receiving an anthracycline and cyclophosphamide, the three-drug combination of a 5-HT3 receptor antagonist, dexamethasone, and aprepitant recommended prechemotherapy; single-agent aprepitant recommended on days 2 and 3 for prevention of delayed emesis.
 For patients receiving an anthracycline and cyclophosphamide and selected patients receiving other chemotherapies of moderate emetic risk (e.g., carboplatin, cisplatin, doxorubicin, epirubicin, ifosfamide, irinotecan, or methotrexate), a 5-HT3 receptor antagonist (ondansetron, granisetron, dolasetron, or palonosetronb), dexamethasone (12 mg), and aprepitant (125 mg) recommended, with or without lorazepam, prechemotherapy; for other patients, aprepitant is not recommended.
For patients receiving other chemotherapies of moderate emetic risk, the two-drug combination of a 5-HT3 receptor antagonist and dexamethasone recommended prechemotherapy; single-agent dexamethasone or a 5-HT3 receptor antagonist recommended on days 2 and 3 for prevention of delayed emesis.
 For prevention of delayed emesis, dexamethasone (8 mg) or a 5-HT3 receptor antagonist on days 2–4 or, if used on day 1, aprepitant (80 mg) on days 2 and 3, with or without dexamethasone (8 mg) on days 2–4, recommended, with or without lorazepam on days 2–4.
Low (10%–30%) risk
 Dexamethasone (8 mg) recommended; no routine preventive use of antiemetics for delayed emesis recommended.
 Metoclopramide, with or without diphenhydramine; dexamethasone (12 mg); or prochlorperazine recommended, with or without lorazepam.
Minimal (<10%) risk
 No antiemetic administered routinely pre- or postchemotherapy.
 No routine prophylaxis; consider using antiemetics listed under primary prophylaxis as treatment.


Refrences:
National Cancer Institute: http://www.cancer.gov/cancertopics/pdq/supportivecare/nausea/HealthProfessional/page6
Sancuso site: http://www.sancuso.com/patient/cinv/types_CINV.php
Hope Navigators: http://www.hopenavigators.com/managing-matters/physical-matters/managing-side-effects/chemotherapy-induced-nausea-and-vomitingGroup 3 - Chemotherapy Induced Nausea and Vomiting